Prognostic Factors in Stage IV Ovarian Carcinoma Treated with Platinum-Based Regimens

Impact of residual disease on overall survival in women with Federation of Gynecology and Obstetrics stage IIIB-IIIC vs stage IV epithelial ovarian cancer after primary surgery

INTRODUCTION

The objective of this study was to determine the impact of intra-abdominal residual disease size, type (carcinomatosis, tumor mass or both), and location (upper/lower abdominal/both) on overall survival in women with Federation of Gynecology and Obstetrics (FIGO) stage IIIB-IIIC vs stage IV epithelial ovarian cancer who underwent primary debulking surgery.

MATERIAL AND METHODS

Altogether 2092 women diagnosed with advanced epithelial ovarian cancer undergoing primary debulking surgery in Denmark during 2005-2016 were identified in the Danish Gynecological Cancer Database. The impact of residual disease size, type, and location were evaluated using univariate and multivariate analyses.

RESULTS

Complete cytoreduction (residual disease = 0) was achieved in 47.3% and 38.4% of women with stage IIIB-IIIC and IV epithelial ovarian cancer, respectively. A benefit in overall survival was observed in women with residual disease = 0 compared with women with residual disease, and among women with residual disease ≤1 cm compared with residual disease >2 cm in both stages IIIB-IIIC and stage IV in multivariate analyses. Multivariate analyses showed an inferior overall survival for women with both residual carcinomatosis and residual tumor mass compared with those with residual tumor mass or residual carcinomatosis only for stage IIIB-IIIC and IV, and an inferior overall survival for women with residual disease located in both the upper and lower abdomen compared with residual disease in the upper abdomen only in stages IIIB-IIIC.

CONCLUSIONS

Our results confirm the positive prognostic impact of both complete cytoreduction and residual disease ≤1 cm in stages IIIB-IIIC as well as stage IV epithelial ovarian cancer. Women with stage IV do benefit from cytoreductive surgery and should be considered for primary debulking surgery, if residual disease = 0 can initially be expected.

Influence of residual tumor on outcome in ovarian cancer patients with FIGO stage IV disease: an exploratory analysis of the AGO-OVAR (Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group)

BACKGROUND

One of the most important prognostic factors in advanced ovarian cancer is the macroscopic absence of residual tumor after primary surgery. The impact of surgical outcome on the survival of patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease is less clear and is the subject of this study.

METHODS

Surgical and survival data were documented throughout the multicenter prospective randomized phase III trials of the AGO-OVAR (OVAR-3/-5/-7) and were used for this exploratory analysis. In these studies, 573 patients with FIGO stage IV disease were first operated, then randomized and homogenously treated with a combination therapy comprising the intravenous application of platinum and paclitaxel.

RESULTS

The median progression-free survival and overall survival of patients with stage IV ovarian cancer were 12.6 and 26.1 months, respectively. Multivariable Cox regression analysis for overall survival revealed that residual tumor, mucinous histological type, multiple sites of metastases, and Eastern Cooperative Oncology Group performance status were statistically significant prognostic variables. Whereas patients with macroscopically complete resection had a statistically significant improved outcome, patients with residual disease of 0.1-1 cm and patients with residual tumor of >1 cm showed similar outcome.

CONCLUSIONS

Macroscopically complete resection in FIGO stage IV disease, irrespective of the site of distant tumor spread, is an important prognostic factor and the only prognosticator amenable to improvement by therapy. Our results suggest possible advantages of a reasonable attempt at complete cytoreduction even in FIGO stage IV disease. In addition, tumor biology could be an important factor for achieving complete resection.

Tumor residual after surgical cytoreduction in prediction of clinical outcome in stage IV epithelial ovarian cancer: a Gynecologic Oncology Group Study

PURPOSE

To identify factors predictive of poor prognosis in a similarly treated population of women with stage IV epithelial ovarian cancer (EOC).

PATIENTS AND METHODS

A retrospective review of 360 patients with International Federation of Gynecology and Obstetrics stage IV EOC who underwent primary surgery followed by six cycles of intravenous platinum/paclitaxel was performed. A proportional hazards model was used to assess the association of potential prognostic factors with progression-free survival (PFS) and overall survival (OS).

RESULTS

The median PFS and OS for this group of stage IV ovarian cancer patients was 12 and 29 months, respectively. Multivariate regression analysis revealed that histology, malignant pleural effusion, intraparenchymal liver metastasis, and residual tumor size were significant prognostic variables. Whereas patients with microscopic residual disease had the best outcome, patients with 0.1 to 1.0 cm residual disease and patients with 1.1 to 5.0 cm residual disease had similar PFS and OS. Patients with a residual size more than 5 cm had a diminished PFS and OS when compared with all other groups. Median OS for microscopic, 0.1 to 5.0 cm, and more than 5.0 cm residual disease was 64, 30, and 19 months, respectively.

CONCLUSION

Patients with more than 5 cm residual disease have the shortest PFS and OS, whereas patients with 0.1 to 1.0 and 1.1 to 5.0 cm have similar outcome. These findings suggest that ultraradical cytoreductive procedures might be targeted for selected patients in whom microscopic residual disease is achievable. Patients with less than 5.0 cm of disease initially and significant disease and/or comorbidities precluding microscopic cytoreduction may be considered for alternative therapeutic options other than primary cytoreduction.